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CONTENTS
Cover
Dedication
Title Page
Copyright
Foreword
Acknowledgements
How to use this book
Introduction
Part I Understanding and Promoting Health
1. What is Health?
Key learning outcomes
Overview
De initions of health
Theoretical perspectives
Lay perspectives
Why is this important for understanding health?
Summary
Questions
Further reading
2. Contemporary Threats to Health
Key learning outcomes
Overview
Conceptualizing the identifying of threats
Why and how is all this important?
Summary
Questions
 Further reading
3. Investigating Health
Key learning outcomes
Overview
What is research?
Philosophical frameworks
Research question/s
Quantitative research
Qualitative research
Differences between quantitative and qualitative
research
Ethics of research
Evidence-based practice
Why is understanding research important?
Summary
Questions
Further reading
Part II The Disciplinary Context of Health Studies
4. Sociology
Key learning outcomes
Overview
What is sociology?
Society as a determinant of health
Sociological theories of health and illness
Sociological critique of health promotion
Why is this important for understanding health?
Summary
Questions
Further reading
5. Social Anthropology
Key learning outcomes
Overview
What is social anthropology?
Culture and health
Experiencing illness
Culture and treatment
Cultural representations
Culture and mental illness
Cultural in luences upon health
Why is this important to health studies?
Summary
Questions
Further reading
6. Health Psychology
Key learning outcomes
Overview
What is health psychology?
How is health psychology important?
Critical perspectives
Summary
Questions
Further reading
7. Health Promotion
Key learning outcomes
Overview
What is health promotion?
Origins of health promotion
Tools for understanding health promotion
 Principles and values
Critiques of health promotion
Contribution of health promotion
Summary
Questions
Further reading
Part III In luences upon Health
8. Individual Characteristics and their In luence upon Health
Key learning outcomes
Overview
What is this all about?
How do individual characteristics in luence health?
What does this mean?
A lifespan perspective
How is this relevant?
Summary
Questions
Further reading
9. Social and Community Characteristics and their In luence
upon Health
Key learning outcomes
Overview
Social and community networks
Social support
Relationship between social support and health
Social capital
Measuring social capital
Relationship between social capital and health
Settings for social and community networks
 Implications for policy and practice
Social and community networks
Summary
Questions
Further reading
10. The Physical Environment and its In luence upon Health
Key learning outcomes
Overview
What is this all about?
Physical environment (living and working conditions)
What does this mean?
How is this relevant?
Summary
Questions
Further reading
11. Policy In luences upon Health
Key learning outcomes
Overview
What is social policy?
Social policy as a determinant of health
Current policy issues
The British Welfare State
Ideological and political values
Health services as a determinant of health
Health in all policies
The broader policy environment
The importance of iscal policy
Social policy and health studies
Summary
 Questions
Further reading
12. The Global Context of Health
Key learning outcomes
Overview
Why is global health important?
How does the global context in luence health?
Why is all of this important?
Summary
Questions
Further reading
13. Synthesizing Perspectives: Case Studies for Action
Key learning outcomes
Overview
The determinants of health ‘rainbow’
Key strengths of the rainbow model
How the rainbow model might be improved
Summary
Glossary
References and suggested reading
Index
End User License Agreement
List of Illustrations
Introduction
Figure i.1 The Dahlgren and Whitehead determinants of
health rainbow
Chapter 2
Figure 2.1 Population pyramids – Zambia
Chapter 3
Figure 3.1 Representative sampling
Chapter 6
Figure 6.1 The Health Belief Model
Figure 6.2 The Theory of Planned Behaviour
Figure 6.3 The Health Action Model
Chapter 7
Figure 7.1 Tannahill’s model of health promotion
Figure 7.2 Beattie’s model of health promotion
Figure 7.3 Tones and Tilford’s model of health promotion
Figure 7.4 Caplan and Holland’s model of health promotion
Part III
Figure iii.1 The Dahlgren and Whitehead determinants of
health rainbow
Chapter 8
Figure 8.1 The health career
Chapter 9
Figure 9.1 Proposed mechanisms of action for social support
Chapter 13
Figure 13.1 Factors in luencing malaria using Dahlgren and
Whitehead’s model as a framework …
Figure 13.2 Factors in luencing cervical cancer using
Dahlgren and Whitehead’s model as a fr…
Figure 13.3 Factors in luencing neighbourhood health using
Dahlgren and Whitehead’s model as…
Figure 13.4 Factors in luencing COVID-19 using Dahlgren and
Whitehead’s model as a framework…
Figure 13.5 Barton and Grant’s ‘health map’ – an extension of
Dahlgren and Whitehead’s model
Figure 13.6 The Commission on the Social Determinants of
Health conceptual framework
List of Tables
Chapter 1
Table 1.1 The medical model of health compared with the
social model of health
Table 1.2 The lay perspective on health
Chapter 2
Table 2.1 Changing patterns of disease, illness and health
Table 2.2 Effects of climate change upon health
Table 2.3 The impact of safety and security upon health
Chapter 3
Table 3.1 Assumptions of different philosophical traditions
Table 3.2 Generating research questions
Table 3.3 Example research questions and methodological
approaches
Table 3.4 An overview of quantitative data-collection
techniques
Table 3.5 An overview of quantitative probability sampling
approaches
Table 3.6 Levels of measurement
Table 3.7 An overview of qualitative data-collection
techniques
Table 3.8 An overview of qualitative sampling approaches
Table 3.9 Stages of drawing upon evidence
Chapter 4
Table 4.1 Summary and critique of explanations of health
inequalities
Chapter 6
 Table 6.1 Different types of behaviour
Chapter 7
Table 7.1 Different types of models
Chapter 11
Table 11.1 Policy changes to English organ donation
Table 11.2 Ideological positions and their implications for
health
Chapter 12
Table 12.1 Comparison of life expectancy and healthy life
expectancy, 2020
Table 12.2 Disparities in global health-care spending
Table 12.3 The key actors in global policy-making
Table 12.4 An overview of the Sustainable Development
Goals
Chapter 13
Table 13.1 Determinants of malaria
Table 13.2 Determinants of cervical cancer
Table 13.3 Determinants of unhealthy neighbourhoods
Table 13.4 Determinants of COVID-19
List of Case Studies
Chapter 1
Case Study 1 Concepts of health and open defecation
Chapter 2
Case Study 2 Global antibiotic resistance
Chapter 3
Case Study 3 Digital data
Chapter 4
Case Study 4 The medical management of sleep
Chapter 5
Case Study 5 The Western culture of well-being
Chapter 6
Case Study 6 Perspectives on skin bleaching
Chapter 7
Case Study 7 Using Caplan and Holland’s model to consider
different approaches to addressing …
Chapter 8
Case Study 8 Individual characteristics and the experience of
HIV/AIDS
Chapter 9
Case Study 9 Asset-based community development in
Northumberland
Chapter 10
Case Study 10 Rural Ghana: the impact of the physical
environment on health
Chapter 11
 Case Study 11 Policy approaches to reducing inequalities
Chapter 12
Case Study 12 Action on the global social determinants of
health
Chapter 13
Case Study 13 Malaria
Case Study 14 Cervical cancer
Case Study 15 Neighbourhoods
Case Study 16 COVID-19
List of Learning Tasks
Chapter 1
Learning tasks 1.1 De ining health
Learning tasks 1.2 Comparing de initions
Learning tasks 1.3 In luences upon health
Learning tasks 1.4 Different people, different de initions
Chapter 2
Learning tasks 2.1 The signi icance of health threats
Learning tasks 2.2 Hypertension and health
Learning tasks 2.3 HPV media coverage
Learning tasks 2.4 Analysing trends in life expectancy
Chapter 3
Learning tasks 3.1 Where do I begin in thinking about my
research project?
Learning tasks 3.2 Choosing an appropriate method for your
project
Learning tasks 3.3 Sampling for your project
Learning tasks 3.4 Appraising evidence for your project
Chapter 4
Learning tasks 4.1 Developing your sociological thinking
about health
Learning tasks 4.2 Thinking about social in luences upon
health
Learning tasks 4.3 Stigma and health: biographical
disruption
Learning tasks 4.4 The social construction of disability
Chapter 5
Learning tasks 5.1 Re lecting upon why culture matters
Learning tasks 5.2 Exploring your own lay beliefs
Learning tasks 5.3 Healthworld, culture and environment
Learning tasks 5.4 Cultural representations of mental illness
Chapter 6
Learning tasks 6.1 Re lection on changing behaviour
Learning tasks 6.2 Re lection on changing behaviour
Learning tasks 6.3 Determinants of health behaviour
Learning tasks 6.4 Limitations of models of behaviour
change
Chapter 7
Learning tasks 7.1 What do you think health promotion is?
Learning tasks 7.2 Applying Beattie’s model of health
promotion
Learning tasks 7.3 Behaviour-change campaigns
Learning tasks 7.4 Ethics in health promotion
Chapter 8
Learning tasks 8.1 Individual characteristics and health
Learning tasks 8.2 The Avon Longitudinal Study of Parents
and Children
Learning tasks 8.3 Personality and motivation
Learning tasks 8.4 The nature/nurture debate and individual
differences
Chapter 9
Learning tasks 9.1 Your social network map
Learning tasks 9.2 Measuring social capital
 Learning tasks 9.3 Example of a connected community?
Learning tasks 9.4 Communities and social capital
Chapter 10
Learning tasks 10.1 The physical environment and health
Learning tasks 10.2 Food scares and health
Learning tasks 10.3 Community-led total sanitation (CLTS)
Learning tasks 10.4 The in luence of the working
environment upon health
Chapter 11
Learning tasks 11.1 The UK media and policy in luence
Learning tasks 11.2 Making health policy work
Learning tasks 11.3 Ideological beliefs
Learning tasks 11.4 Policy sectors and health implications
Chapter 12
Learning tasks 12.1 Global health challenges
Learning tasks 12.2 Investigating the impact of health
professional migration
Learning tasks 12.3 Globalization, the environment and
health
Learning tasks 12.4 Were the Millennium Development
Goals a success?
Chapter 13
Learning tasks 13.1 Using Dahlgren and Whitehead as an
analytical tool
Learning tasks 13.2 Strategies for tackling health problems
Learning tasks 13.3 Evaluating Dahlgren and Whitehead’s
rainbow model
Learning tasks 13.4 Building on the rainbow model of health
List of Boxes
Chapter 2
Box 2.1 Media and moral panics (selected examples)
Box 2.2 Examples of wide-ranging health inequalities
Chapter 3
Box 3.1 An example of a mixed method evaluation
Box 3.2 Principles of research ethics
Chapter 4
Box 4.1 An example of sociological theory – Parson’s sick role
Box 4.2 An example of sociological theory – Goffman and the
concept of stigma
Box 4.3 An example of sociological theory – medicine for
pro it
Box 4.4 An example of sociological theory – the
medicalization of women’s bodies
Box 4.5 Key sociological questions about health promotion
Chapter 5
Box 5.1 An example of cultural norms affecting health
behaviour
Box 5.2 An example of cultural interpretations of illness
Box 5.3 Lay beliefs about cancer screening
Box 5.4 HIV/AIDS and stigma
Box 5.5 Medicine and the construction of health problems
Chapter 6
Box 6.1 Application of the HBM to testicular self-examination
(might also be applied in…
 Box 6.2 Application of the Theory of Planned Behaviour to
taking up yoga
Box 6.3 Application of Protection Motivation Theory to
condom use
Box 6.4 Application of the Stages of Change Model to
changing eating behaviour (reducing…
Box 6.5 General critiques of behaviour change models in
health psychology
Chapter 7
Box 7.1 Common features of new public health and health
promotion
Box 7.2 Levels of prevention
Box 7.3 Upstream approaches in health promotion
Chapter 8
Box 8.1 The example of Foetal Alcohol Spectrum Disorder
(FASD)
Box 8.2 Key life stages
Box 8.3 Social and economic in luences upon health
Box 8.4 Addictive personality
Box 8.5 Levels of motivation applied to the issue of safer sex
(after the Health Action…
Chapter 9
Box 9.1 Different types of social capital
Box 9.2 The importance of family ties for health
Box 9.3 Examples of social capital and faith-based
organizations
Chapter 11
Box 11.1 Challenges for the English NHS
 Box 11.2 Rationing health care – the role of NICE in the UK
Box 11.3 Important debates in the provision of welfare
Box 11.4 UK Fiscal Policy – Austerity and health outcomes
Chapter 12
Box 12.1 De ining global health
Box 12.2 Globalization and health
Box 12.3 Overview of health tourism
Box 12.4 Examples of unethical trade practices
Box 12.5 Inequalities in global health
Dedication
To
Alex, Maia, Milana, Meadow and Race
To
Evie-Joy William – love you to the moon and back
Contemporary Health Studies
An Introduction
2nd edition
Louise Warwick-Booth
Ruth Cross
Diane Lowcock

polity
Copyright © Louise Warwick-Booth, Ruth Cross & Diane Lowcock 2021
The right of Louise Warwick-Booth, Ruth Cross and Diane Lowcock to be identi ied
as Author of this Work has been asserted in accordance with the UK Copyright,
Designs and Patents Act 1988.
First edition published in 2012 by Polity Press
This second edition irst published in 2021 by Polity Press
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ISBN-13: 978-1-5095-3954-3
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Names: Warwick-Booth, Louise, author. | Cross, Ruth, author. | Lowcock, Diane,
author.
Title: Contemporary health studies : an introduction / Louise Warwick-Booth, Ruth
Cross, and Diane Lowcock.
Description: 2nd edition. | Cambridge, UK ; Medford, MA : Polity, 2021. | Includes
bibliographical references and index. | Summary: “A comprehensive and rigorous
introduction to the ield”-- Provided by publisher.
Identi iers: LCCN 2020033042 (print) | LCCN 2020033043 (ebook) | ISBN
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Subjects: MESH: Social Determinants of Health | Health Status Indicators | Global
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Classi ication: LCC RA418 (print) | LCC RA418 (ebook) | NLM WA 30 | DDC 362.1--
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Foreword
I welcome the second edition of this excellent text. The Introduction
sets out what the book is designed to provide and it delivers on these
promises. One test of a book is that it engages the reader from the
outset. The early chapter on Contemporary Threats to Health led me to
think about the way some speci ic threats were perceived at the start of
my own professional life in health promotion. At that time, the impact
of the physical environment on health was addressed but there was
little mention of climate change; some discussion of malnutrition
associated with food shortages and nutritional de icits but less with
obesity; there was early discussion of what became known as HIV/AIDS
but little general consideration of pandemics; and there was a growing
recognition that health inequalities in the UK continued to exist, despite
the welfare state. Where inequalities were concerned, the nature of
these was analysed and explanations for them debated, especially after
the 1980 Black Report and the reports that followed, and strategies to
ameliorate them were discussed. I recall some optimism that as
appropriate strategies were identi ied there would be the will to
implement them and a reduction of inequalities would follow. Over the
intervening years there have been policies and actions with the
potential to reduce health inequalities, with initiatives to reduce child
poverty being one example; but they have not been sustained, and
inequalities continue to prevail. Moreover, there is the realization that
COVID-19 has led to a further widening of gaps. In comparison with
that early naive optimism, the resistance to implementing changes
designed to achieve greater health equity is now very clear. This book
provides a thorough consideration of health inequalities, which should
enable health-studies students to understand their nature and make
future contributions to the task of overcoming these and the other key
barriers to achieving health for all.
Health studies is a distinct discipline, which integrates concepts and
theories from contributory ones. There will be debates about what
these disciplines should be and the relative weight to be given to each.
In this book, the authors focus on four key ones and give readers the
tools to draw on each of these in analysing health matters. The later
chapter on social policy provides a further important disciplinary
perspective. The guidance on how to use the book makes readers aware
from the outset that they will be on a journey in which they will re lect
on and critique the meanings of health and the in luences on it, as well
as examining conceptual models of health and its determinants.
Although a social model informs the book, readers are enabled to think
critically about all models and, speci ically, to compare and contrast the
social and medical ones. The encouragement to readers to think about
health in salutogenic terms and not simply as absence of disease – and
to consider lay as well as professional perspectives – is important. The
use of the Dahlgren and Whitehead model in the third section, and
modi ications to include a stronger global emphasis, is a particular
strength of the book. In analysing health issues this model facilitates
the consideration of multi-level in luences and their interactions.
Given the scope of health studies, ensuring that depth is not sacri iced
to breadth is a challenge. The authors have successfully met this
challenge. Their own extensive teaching experience in health studies
and health promotion is evident in the clarity of their explanations of
complex ideas, while encouraging readers to re lect on these ideas and
read further. Relevant theory is drawn upon throughout the book and
critiques offered. The inclusion of learning tasks and case studies,
particularly the integrative ones in the last chapter, all serve to keep the
reader actively engaged. These updated case studies provide excellent
models for analysing existing and newly emergent health issues, such
as COVID-19. Although each of the chapters contributes to an
integrated whole, many can stand alone. The Investigating Health
chapter, for example, offers a succinct but critical introduction to the
research process and could usefully be read by students on courses
other than health-related ones. I especially welcome the global focus of
the book and this is informed by the professional experience of the
authors. Overall, the book offers an excellent amalgam of content,
theory, critique and practical examples. While offering an essential text
for health-studies courses, it can be strongly recommended to related
ones.
Sylvia Tilford
Emeritus Professor of Health Promotion, Leeds Beckett University
Acknowledgements
The authors would like to thank the following people:
Polity for commissioning us to work on this second edition and
supporting us in developing the updated materials.
The reviewers for providing constructive feedback on the development
of the book proposal, and the draft manuscript.
The members of the Centre for Health Promotion Research team, and
the wider Health Promotion subject group, for their regular support,
commitment to research and teaching, and ongoing engagement in
critical, re lective discussions about the discipline and teaching.
The diverse range of students that we continue to teach, who challenge
us to keep learning, to develop our practice and to re ine our approach
on a continuous basis. We look forward to continuing to work with you
and hope to keep learning alongside you.
Picture credits
p. 10 Dollar Gill, Unsplash; 20 bruce mars, Unsplash; 30 Hello I’m Nik,
Unsplash; 41 Philippe Leone, Unsplash; 63 © zoran mircetic/iStock; 64
© kate_sept2004/ iStock; 87 code6d/iStock; 96 Wikimedia Commons;
106 © sturti/iStock; 113 © Hans Hillewaert, Wikimedia Commons; 132
Wikimedia Commons; 140 © Adam Jones, Flickr; 147 © Kent
Rosengaard/iStock; 170 © baona/iStock; 177 vikram sundaramoorthy,
Unsplash; 193 © tttuna/iStock; 198 © FangXiaNuo/iStock; 207
Wikimedia Commons; 209 Wikimedia Commons; 227 Wikimedia
Commons; 233 © Karen Town/ iStock; 246 © Fiona Henderson, Flickr;
249 © Gumpanat, iStock; 261 © Kwangmoozaa, iStock; 275 United
Nations, Unsplash.
How to use this book
This section is designed to help you get the most out of this book. The
book aims to provide an in-depth multi-disciplinary overview of the
ield of ‘health studies’. Contemporary Health Studies focuses on what
health studies is about as a discipline, examining how health is
conceptualized in various ways and how it might be understood from a
variety of different disciplinary perspectives. Health is known to be
strongly in luenced by social factors as well as individual ones and this
book aims to explore this idea in some depth.
The book does not promote a particular theoretical viewpoint because
health studies as a discipline draws upon a range of theoretical stances
to allow for different perspectives to be applied to health-related issues.
Indeed, the discipline encourages students to engage critically in the
numerous discourses surrounding health. The book therefore
examines, throughout the text, human experience of health as it is
mediated by individual, societal and global contexts, putting particular
emphasis on the social, political and environmental dimensions of
health. An understanding of these issues is absolutely essential for
contemporary health practitioners. Thus, the book contains a strong,
up-to-date, social-scienti ic focus all the way through. The book is
primarily geared towards undergraduate students undertaking a
public-health-related course. However, it will also be very useful for
undergraduate students studying a wide range of generic health-related
courses, including clinical programmes such as dietetics, environmental
health and nursing. Students studying health promotion will also ind
this book invaluable. Students at all levels of undergraduate study will
be able to engage with the content and it should prove to be a useful
companion to undergraduate programmes other than health studies.
Whatever the speci ic ‘health’ focus of their course this book should
enable students to engage actively with their learning and
contemporary debates about health by providing active and meaningful
opportunities to learn and re lect.
This book is designed to be used in several different ways. It can be
read as a whole – from start to inish – since the chapters are organized
in a logical sequence. Alternatively, readers might wish to select certain
chapters for attention, depending on their interest or concerns and
what might be relevant to them. Sections of each chapter that relate to
other parts of the book have been highlighted in the text through cross-
referencing, so that the reader can follow ideas and topic areas without
having to read the whole book from cover to cover. The book is an
introductory level text and so offers a comprehensive and
contemporary framework of key topic areas within the discipline of
health studies. It contains useful references to further reading,
resources and additional material available on the companion website,
allowing scope for those who wish to explore in more depth.
The book is also divided into three coherent parts and each part can be
read independently of the whole. The irst part sets the context for the
book, exploring what health is, contemporary threats to health and how
we investigate it; the second part focuses on disciplinary perspectives
such as sociology, anthropology, health psychology and health
promotion; the third part looks at in luences upon health, ending with a
set of contemporary case studies that brings everything together.
Part I
Chapter 1 – What is Health?
Chapter 1 will be useful to students on any health-related and health-
professional courses, as it explores the fundamental question ‘What is
health?’, providing an overview of how health is conceptualized and
understood. Understanding different perspectives and theories on
health is foundational to learning about health and training, in any
profession, to promote health. This chapter is also a necessary read in
order to contextualize the debate within subsequent chapters.

Chapter 2 – Contemporary Threats to Health

This chapter identi ies and explores contemporary threats to health. It
is a useful and interesting read for all those working in the public-
health ield because it helps to identify public-health objectives within
the UK and globally. The chapter also provides insight into the nature of
these threats and the factors that in luence speci ic issues that are
identi ied as such threats. Hence, it encourages thought about the
processes associated with de ining contemporary threats to health and
also identi ies threats that are less obvious, such as terrorism.
Ultimately, this chapter is a unique summary of the contemporary
threats to health.

Chapter 3 – Investigating Health

In every profession, including health, there is the need to evaluate new
information, particularly as evidence-based practice has become so
important in recent years. However, there is often not enough evidence
or there may even be competing research indings, so the need to
evaluate and research constantly remains ever present. This chapter is
therefore an essential read for all those studying health, as it will enable
them to understand the key components of the research process and
therefore to interpret research indings. Furthermore, a key stage of
completing an undergraduate degree is the completion of an honours
project or dissertation; this chapter has been written with this
speci ically in mind and so is an ideal guide to help students on their
journey in completing such undergraduate projects. Indeed, many
undergraduate Quality Assurance Agency benchmark statements make
clear reference to the importance of research within their programmes,
so this chapter is a fundamental read for all health students.
Part II
Chapter 4 – Sociology
Chapter 4 will be useful for all health students because it outlines the
focus of the discipline of sociology speci ically in relation to health and
illness. Readers will gain an insight into the social world from the point
of view of sociologists and therefore begin to be able to develop new
perspectives, understand various theoretical viewpoints and think
critically about social situations in terms of both structure and agency.
The focus in this chapter upon health as social and the importance of
health inequalities is a central theme for those completing health-
studies degrees. In addition, this chapter is a useful introductory
resource for broader health professionals such as nurses, allied health
professionals and those studying health promotion, who are often
required to complete sociology modules as part of their degree
programmes.

Chapter 5 – Social Anthropology

This chapter gives an insight into the relationship between health and
culture, demonstrating the importance of lay beliefs in relation to
understanding health and treatment. It is important for those
completing undergraduate health programmes because it further
enhances their knowledge about the importance of the social in
relation to health. The chapter also facilitates the ability of the reader to
make comparisons between a range of health contexts. The chapter is
again relevant to any health professional because it creates an
awareness of different cultural settings and draws attention to the
importance of the everyday understandings (lay perspectives) that co-
exist alongside medical and professional viewpoints.

Chapter 6 – Health Psychology

This chapter focuses on a discipline that makes a major contribution to
public health. Health psychology is fundamental in many ways and for
many reasons, as it is about exploring the ways in which people behave
in relation to their health. Underpinning behaviour is a range of
complex in luences, which this chapter explores, drawing on theory and
recent research in the discipline. This chapter will be of interest to
students on a range of health-related courses as well as those on
health-professional courses, such as nursing, and other allied health
professions that encourage and facilitate behaviour change at an
individual level through one-to-one encounters. Of course, students of
psychology, especially health psychology, will ind this useful reading
for their studies.

Chapter 7 – Health Promotion

This chapter provides the reader with an introduction to health
promotion and gives an overview of the frameworks used to underpin
health-promotion practice. It also outlines the principles and values
that underpin health promotion, so the chapter is an excellent
introduction to all of those interested in learning about health
promotion. The chapter is essential for students who are beginning to
study health promotion across a range of subject areas, such as health
studies, health promotion and public health. It is also a useful resource
for inter-professional health care students and nurses who are often
required to undertake health-promotion modules and is internationally
relevant because health promotion is practised across the world in a
variety of contexts.
Part III
Part III of the book takes the reader on a journey, looking at in luences
upon health, starting at the individual level and moving on to consider
wider structural factors, such as the importance of global society. It
draws explicitly on Dahlgren and Whitehead’s determinants of health
model, using it as a framework for developing understanding about the
determinants of health; the chapters are therefore structured to re lect
this.

Chapter 8 – Individual Characteristics and their

Influence upon Health
This chapter explores critically a range of individual characteristics that
in luence health. Some of the topics covered include foetal
programming, the in luence of age, the in luence of biological sex and
gender and the in luence of personality. The range of subject matter
means that it will be of general interest to students on a variety of
different health-related courses. This chapter can be read alongside
Chapter 6, which focuses on behaviour at an individual level. It may be
of particular interest to students studying for a range of health
professions that consider individual differences and development
across the lifespan.

Chapter 9 – Social and Community

Characteristics and their Influence upon Health
This chapter explores how social and community networks act as
determinants of health. Two major concepts, social support and social
capital, are de ined and debated and evidence presented of their
relationship to health status. The proposed mechanisms of how social
support and social capital in luence health are explained. In the inal
section the implications for policy-makers and practitioners of social
and community network in luences upon health are considered. This
chapter is useful for all those studying public health, health promotion
and health studies, as social capital is increasingly cited as an important
health determinant and is used within contemporary policy. The
chapter will also be of interest to those working with communities in
any context, such as community development workers and community
nurses.

Chapter 10 – The Physical Environment and its

Influence upon Health
This chapter considers a range of factors within our physical
environments that impact on health. These include all of the factors
that appear in Dahlgren and Whitehead’s framework, namely
agriculture and food production, education, working environments,
water and sanitation, and housing. Each factor is considered in critical
depth, drawing on recent research indings and debate. This chapter
may be of particular interest to students of environmental health;
however, it will also have relevance to a wide variety of health-related
courses.

Chapter 11 – Policy Influences upon Health

Social policy permeates all areas of society and is the subject of
everyday discussion and daily experiences. It is also controversial and
often debated; hence this chapter is essential reading for anyone who is
studying health because social policy is fundamentally about who is
entitled to support from the state in terms of both health and welfare
and the kinds of support that can and should be provided. The chapter
explores what social policy is, how it is made, the ideological basis of
policy and offers an insight into how many policy sectors have an
impact upon health. The chapter draws speci ically upon UK health
policy and so is a useful resource for practitioners, nurses and students
of health studies as a general introduction to the area.

Chapter 12 – The Global Context of Health

Dahlgren and Whitehead’s framework does not make reference to the
importance of the global context of health but, given the way in which
the world is more closely connected through the processes associated
with globalization, it is essential to understand how the global context
in luences and determines health outcomes. Globalization is a key
determinant of health. This chapter uses the concept of globalization
speci ically to explore health within the global context, examining
global health patterns, inequalities, health care and governance,
including the Sustainable Development Goals. Given that health is
global in so many respects, as this chapter demonstrates, this is an
essential read for everyone studying health or working in a health
profession.

Chapter 13 – Synthesizing Perspectives: Case

Studies for Action
Chapter 13 brings everything that has been discussed in previous
chapters together. It provides three detailed case studies, which
consider much of the content of the book in relation to speci ic and
contemporary public-health challenges. The individual case studies are
about malaria, cervical cancer, neighbourhoods and strategies to tackle
COVID-19. Each case study introduces the issue in depth and then
considers ways in which health might be promoted in relation to it. The
chapter then considers Dahlgren and Whitehead’s determinants of
health rainbow framework critically and in some depth, examining its
strengths and how it might be improved upon. This chapter will be
useful to those working in the public-health ield because it
demonstrates the application of different schools of knowledge to
speci ic health problems. Consequently, readers gain practice-related
insights here, as well as the ability to build upon the theoretical
understandings provided across the earlier chapters.
Introduction
The overall aim of this volume is to enable the reader to examine how
health is conceptualized in various ways and how it is understood from
a variety of disciplinary perspectives (terms in bold appear in the
Glossary at the end of the book). Health studies is a distinct discipline
in its own right, which attempts to explore all of the factors that can and
do in luence health, while examining the very meaning of health itself,
which is the starting point for this book in chapter 1. As the scope of
health studies is extremely large, this book will enable the reader to
focus upon the central tenets of health studies by exploring the human
experience of health across several contexts; for example, community
in chapter 9, the environment in chapter 10, the policy context in
chapter 11 and the global context in chapter 12. The book also
discusses critically and analyses the many factors that are in luential in
relation to health, such as the contemporary threats to health that are
considered in chapter 2 and the individual characteristics considered
in chapter 8. Indeed, as there are many diverse discourses that
surround health, these are illustrated in detailed case studies
throughout the chapters. Health studies is also interdisciplinary in its
nature and so draws upon many different disciplines, including
sociology (chapter 4), anthropology, (chapter 5), psychology (chapter
6) and health promotion (chapter 7). Through the examination of
different disciplines and in luences, health is shown to be
overwhelmingly socially in luenced, and is situated within a multi-
disciplinary critical framework. The key strength of health studies as a
discipline is its ability to synergise understandings and in luences from
a variety of ields, as chapter 13 clearly demonstrates. Indeed, another
key aspect of the discipline of health studies is the scope of analysis that
can be achieved across a variety of ields, aided by the examination of
evidence and research indings, which are discussed in detail in
chapter 3. Through easy to navigate interactive chapters this book also
enables the reader to develop and enhance subject speci ic skills, such
as the ability to compare health contexts and to understand the range
of in luences upon health (part III), the ability to draw upon research
methodologies and to analyse research indings (chapter 3) and the
ability to enhance theoretical understandings (part II).
Detailed outline of the book
This book is divided into three parts, which take readers on a journey
through several speci ic areas related to health studies. The irst part of
the book, Understanding and Promoting Health, begins with three
chapters that introduce the reader to key issues within the ield of
health studies. From the outset, these chapters encourage students to
begin to think both critically and re lectively about health. Chapter 1
tackles the very complex question of What is Health? Readers are
encouraged to consider the concept of health critically and in depth
and to think deeply about a concept that is often taken for granted, by
considering de initions and conceptions of health. Widespread
understandings of health as the absence of disease are challenged
through discussions drawing upon both lay and theoretical
perspectives. The second chapter in this irst part of the book gives a
critical overview of the main contemporary threats, issues and
challenges in relation to public health within the twenty- irst century,
considering a range of both communicable and non-communicable
diseases, and broader threats such as climate change. This chapter also
explores the ways in which these problems can be tackled through both
prevention and treatment. The third and inal chapter in this irst part
tackles the importance of research in relation to health and health
studies. This chapter introduces students to the entire research
process, discussing the methods and processes by which information
about health is gathered, analysed and used. The chapter demonstrates
that health can be investigated in a number of different ways, exploring
both quantitative and qualitative approaches to researching health. The
strengths and weaknesses of these different techniques for gathering
data are also considered. Readers are also shown how to formulate
questions about health and how to decide upon the most appropriate
research approaches, with the chapter offering practical examples to
support those working on dissertations.
The second part of the book is called Disciplinary Context and
introduces the reader to four speci ic disciplinary areas that all have
relevance and in luence within the health-studies arena. Hence, this
section introduces the reader to the disciplinary context in which
Another random document with
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trousers, a narghile, and a mosque slightly larger than the narghile)
could never cause to look like anything except a disguised bed. She
was curled up, pinching her ankle with one tired and nervous hand,
and reading a stimulating chapter of Laura Jean Libbey. Her shirt-
waist was open at the throat, and down her slim stocking was a
grievous run. She was so un-Juanita-like—an ash-blonde, pale and
lovely, with an ill-restrained passion in her blue eyes.
Nellie, a buxom jolly child, dark as a Jewess, was wearing a
frowsy dressing-gown. She was making coffee and narrating her
grievances against her employer, the pious dressmaker, while
Juanita paid no attention whatever.
The young men crept into the room without knocking.
“You devils—sneaking in like this, and us not dressed!” yelped
Nellie.
Jim sidled up to her, dragged her plump hand away from the
handle of the granite-ware coffee-pot, and giggled, “But aren’t you
glad to see us?”
“I don’t know whether I am or not! Now you quit! You behave, will
you?”
Rarely did Elmer seem more deft than Jim Lefferts. But now he
was feeling his command over women—certain sorts of women.
Silent, yearning at Juanita, commanding her with hot eyes, he sank
on the temporarily Oriental couch, touched her pale hand with his
broad finger-tips, and murmured, “Why, you poor kid, you look so
tired!”
“I am and— You hadn’t ought to of come here this afternoon.
Nell’s aunt threw a conniption fit the last time you were here.”
“Hurray for aunty! But you’re glad to see me?”
She would not answer.
“Aren’t you?”
Bold eyes on hers that turned uneasily away, looked back, and
sought the safety of the blank wall.
“Aren’t you?”
She would not answer.
 “Juanita! And I’ve longed for you something fierce, ever since I
saw you!” His fingers touched her throat, but softly. “Aren’t you a little
glad?”
As she turned her head, for a second she looked at him with
embarrassed confession. She sharply whispered, “No—don’t!” as he
caught her hand, but she moved nearer to him, leaned against his
shoulder.
“You’re so big and strong,” she sighed.
“But, golly, you don’t know how I need you! The president, old
Quarles—quarrels is right, by golly, ha, ha, ha!—’member I was
telling you about him?—he’s laying for me because he thinks it was
me and Jim that let the bats loose in chapel. And I get so sick of that
gosh-awful Weekly Bible Study—all about these holy old gazebos.
And then I think about you, and gosh, if you were just sitting on the
other side of the stove from me in my room there, with your cute lil
red slippers cocked up on the nickel rail—gee, how happy I’d be!
You don’t think I’m just a bonehead, do you?”
Jim and Nellie were at the stage now of nudging each other and
bawling, “Hey, quit, will yuh!” as they stood over the coffee.
“Say, you girls change your shirts and come on out and we’ll blow
you to dinner, and maybe we’ll dance a little,” proclaimed Jim.
“We can’t,” said Nellie. “Aunty’s sore as a pup because we was
up late at a dance night before last. We got to stay home, and you
boys got to beat it before she comes in.”
“Aw, come on!”
“No, we can’t!”
“Yuh, fat chance you girls staying home and knitting! You got
some fellows coming in and you want to get rid of us, that’s what’s
the trouble.”
“It is not, Mr. James Lefferts, and it wouldn’t be any of your
business if it was!”
While Jim and Nellie squabbled, Elmer slipped his hand about
Juanita’s shoulder, slowly pressed her against him. He believed with
terrible conviction that she was beautiful, that she was glorious, that
she was life. There was heaven in the softness of her curving
shoulder, and her pale flesh was living silk.
“Come on in the other room,” he pleaded.
“Oh—no—not now.”
He gripped her arm.
“Well—don’t come in for a minute,” she fluttered. Aloud, to the
others, “I’m going to do my hair. Looks just ter-ble!”
She slipped into the room beyond. A certain mature self-reliance
dropped from Elmer’s face, and he was like a round-faced big baby,
somewhat frightened. With efforts to appear careless, he fumbled
about the room and dusted a pink and gilt vase with his large
crumpled handkerchief. He was near the inner door.
He peeped at Jim and Nellie. They were holding hands, while the
coffee-pot was cheerfully boiling over. Elmer’s heart thumped. He
slipped through the door and closed it, whimpering, as in terror:
“Oh—Juanita—”

VI
They were gone, Elmer and Jim, before the return of Nellie’s
aunt. As they were not entertaining the girls, they dined on pork
chops, coffee, and apple pie at the Maginnis Lunch.
It has already been narrated that afterward, in the Old Home
Sample Room, Elmer became philosophical and misogynistic as he
reflected that Juanita was unworthy of his generous attention; it has
been admitted that he became drunk and pugnacious.
As he wavered through the sidewalk slush, on Jim’s arm, as his
head cleared, his rage increased against the bully who was about to
be encouraged to insult his goo’ frien’ and roommate. His shoulders
straightened, his fists clenched, and he began to look for the
scoundrel among the evening crowd of mechanics and coal-miners.
They came to the chief corner of the town. A little way down the
street, beside the red brick wall of the Congress Hotel, some one
was talking from the elevation of a box, surrounded by a jeering
gang.
 “What they picking on that fella that’s talking for? They better let
him alone!” rejoiced Elmer, throwing off Jim’s restraining hand,
dashing down the side street and into the crowd. He was in that most
blissful condition to which a powerful young man can attain—
unrighteous violence in a righteous cause. He pushed through the
audience, jabbed his elbow into the belly of a small weak man, and
guffawed at the cluck of distress. Then he came to a halt, unhappy
and doubting.
The heckled speaker was his chief detestation, Eddie Fislinger,
president of the Terwillinger College Y. M. C. A., that rusty-haired
gopher who had obscenely opposed his election as president.
With two other seniors who were also in training for the Baptist
ministry, Eddie had come over to Cato to save a few souls. At least,
if they saved no souls (and they never had saved any, in seventeen
street meetings) they would have handy training for their future jobs.
Eddie was a rasping and insistent speaker who got results by
hanging to a subject and worrying it, but he had no great boldness,
and now he was obviously afraid of his chief heckler, a large, blond,
pompadoured young baker, who bulked in front of Eddie’s rostrum
and asked questions. While Elmer stood listening, the baker
demanded:
“What makes you think you know all about religion?”
“I don’t pretend to know all about religion, my friend, but I do
know what a powerful influence it is for clean and noble living, and if
you’ll only be fair now, my friend, and give me a chance to tell these
other gentlemen what my experience of answers to prayer has been
—”
“Yuh, swell lot of experience you’ve had, by your looks!”
“See here, there are others who may want to hear—”
Though Elmer detested Eddie’s sappiness, though he might have
liked to share drinks with the lively young baker-heckler, there was
no really good unctuous violence to be had except by turning
champion of religion. The packed crowd excited him, and the
pressure of rough bodies, the smell of wet overcoats, the rumble of
mob voices. It was like a football line-up.
 “Here, you!” he roared at the baker. “Let the fellow speak! Give
him a chance. Whyn’t you pick on somebody your own size, you big
stiff!”
At his elbow, Jim Lefferts begged, “Let’s get out of this, Hell-cat.
Good Lord! You ain’t going to help a gospel-peddler!”
Elmer pushed him away and thrust his chest out toward the
baker, who was cackling, “Heh! I suppose you’re a Christer, too!”
“I would be, if I was worthy!” Elmer fully believed it, for that
delightful moment. “These boys are classmates of mine, and they’re
going to have a chance to speak!”
Eddie Fislinger bleated to his mates, “Oh, fellows, Elm Gantry!
Saved!”
Even this alarming interpretation of his motives could not keep
Elmer now from the holy zeal of fighting. He thrust aside the one
aged man who stood between him and the baker—bashing in the
aged one’s derby and making him telescope like a turtle’s neck—and
stood with his fist working like a connecting-rod by his side.
“If you’re looking for trouble—” the baker suggested, clumsily
wobbling his huge bleached fists.
“Not me,” observed Elmer and struck, once, very judiciously, just
at the point of the jaw.
The baker shook like a skyscraper in an earthquake and caved to
the earth.
One of the baker’s pals roared, “Come on, we’ll kill them guys
and—”
Elmer caught him on the left ear. It was a very cold ear, and the
pal staggered, extremely sick. Elmer looked pleased. But he did not
feel pleased. He was almost sober, and he realized that half a dozen
rejoicing young workmen were about to rush him. Though he had an
excellent opinion of himself, he had seen too much football, as
played by denominational colleges with the Christian
accompaniments of kneeing and gouging, to imagine that he could
beat half a dozen workmen at once.
 It is doubtful whether he would ever have been led to further
association with the Lord and Eddie Fislinger had not Providence
intervened in its characteristically mysterious way. The foremost of
the attackers was just reaching for Elmer when the mob shouted,
“Look out! The cops!”
The police force of Cato, all three of them, were wedging into the
crowd. They were lanky, mustached men with cold eyes.
“What’s all this row about?” demanded the chief.
He was looking at Elmer, who was three inches taller than any
one else in the assembly.
“Some of these fellows tried to stop a peaceable religious
assembly—why, they tried to rough-house the Reverend here—and I
was protecting him,” Elmer said.
“That’s right, Chief. Reg’lar outrage,” complained Jim.
“That’s true, Chief,” whistled Eddie Fislinger from his box.
“Well, you fellows cut it out now. What the hell! Ought to be
ashamed yourselves, bullyragging a Reverend! Go ahead,
Reverend!”
The baker had come to, and had been lifted to his feet. His
expression indicated that he had been wronged and that he wanted
to do something about it, if he could only find out what had
happened. His eyes were wild, his hair was a muddy chaos, and his
flat floury cheek was cut. He was too dizzy to realize that the chief of
police was before him, and his fuming mind stuck to the belief that
he was destroying all religion.
“Yah, so you’re one of them wishy-washy preachers, too!” he
screamed at Elmer—just as one of the lanky policemen reached out
an arm of incredible length and nipped him.
The attention of the crowd warmed Elmer, and he expanded in it,
rubbed his mental hands in its blaze.
“Maybe I ain’t a preacher! Maybe I’m not even a good Christian!”
he cried. “Maybe I’ve done a whole lot of things I hadn’t ought to of
done. But let me tell you, I respect religion—”
“Oh, amen, praise the Lord, brother,” from Eddie Fislinger.
 “—and I don’t propose to let anybody interfere with it. What else
have we got except religion to give us hope—”
“Praise the Lord, oh, bless his name!”
“—of ever leading decent lives, tell me that, will you, just tell me
that!”
Elmer was addressing the chief of police, who admitted:
“Yuh, I guess that’s right. Well now, we’ll let the meeting go on,
and if any more of you fellows interrupt—” This completed the chief’s
present ideas on religion and mob-violence. He looked sternly at
everybody within reach, and stalked through the crowd, to return to
the police station and resume his game of seven-up.
Eddie was soaring into enchanted eloquence:
“Oh, my brethren, now you see the power of the spirit of Christ to
stir up all that is noblest and best in us! You have heard the
testimony of our brother here, Brother Gantry, to the one and only
way to righteousness! When you get home I want each and every
one of you to dig out the Old Book and turn to the Song of Solomon,
where it tells about the love of the Savior for the Church—turn to the
Song of Solomon, the fourth chapter and the tenth verse, where it
says—where Christ is talking about the church, and he says—Song
of Solomon, the fourth chapter and the tenth verse—‘How fair is thy
love, my sister, my spouse! how much better is thy love than wine!’
“Oh, the unspeakable joy of finding the joys of salvation! You
have heard our brother’s testimony. We know of him as a man of
power, as a brother to all them that are oppressed, and now that he
has had his eyes opened and his ears unstopped, and he sees the
need of confession and of humble surrender before the throne
— Oh, this is a historic moment in the life of Hell-c—— of Elmer
Gantry! Oh, Brother, be not afraid! Come! Step up here beside me,
and give testimony—”
“God! We better get outa here quick!” panted Jim.
“Gee, yes!” Elmer groaned, and they edged back through the
crowd, while Eddie Fislinger’s piping pursued them like icy and
penetrating rain:
 “Don’t be afraid to acknowledge the leading of Jesus! Are you
boys going to show yourselves too cowardly to risk the sneers of the
ungodly?”
They were safely out of the crowd, walking with severe
countenances and great rapidity back to the Old Home Sample
Room.
“That was a dirty trick of Eddie’s!” said Jim.
“God, it certainly was! Trying to convert me! Right before those
muckers! If I ever hear another yip out of Eddie, I’ll knock his block
off! Nerve of him, trying to lead me up to any mourners’ bench! Fat
chance! I’ll fix him! Come on, show a little speed!” asserted the
brother to all them that were oppressed.
By the time for their late evening train, the sound conversation of
the bartender and the sound qualities of his Bourbon had caused
Elmer and Jim to forget Eddie Fislinger and the horrors of
undressing religion in public. They were the more shocked, then,
swaying in their seat in the smoker, to see Eddie standing by them,
Bible in hand, backed by his two beaming partners in evangelism.
Eddie bared his teeth, smiled all over his watery eyes, and
caroled:
“Oh, fellows, you don’t know how wonderful you were tonight!
But, oh, boys, now you’ve taken the first step, why do you put it off—
why do you hesitate—why do you keep the Savior suffering as he
waits for you, longs for you? He needs you boys, with your splendid
powers and intellects that we admire so—”
“This air,” observed Jim Lefferts, “is getting too thick for me. I
seem to smell a peculiar and a fishlike smell.” He slipped out of the
seat and marched toward the forward car.
Elmer sought to follow him, but Eddie had flopped into Jim’s
place and was blithely squeaking on, while the other two hung over
them with tender Y. M. C. A. smiles very discomforting to Elmer’s
queasy stomach as the train bumped on.
For all his brave words, Elmer had none of Jim’s resolute
contempt for the church. He was afraid of it. It connoted his
boyhood. . . . His mother, drained by early widowhood and drudgery,
finding her only emotion in hymns and the Bible, and weeping when
he failed to study his Sunday School lesson. The church, full thirty
dizzy feet up to its curiously carven rafters, and the preachers, so
overwhelming in their wallowing voices, so terrifying in their pictures
of little boys who stole watermelons or indulged in biological
experiments behind barns. The awe-oppressed moment of his
second conversion, at the age of eleven, when, weeping with
embarrassment and the prospect of losing so much fun, surrounded
by solemn and whiskered adult faces, he had signed a pledge
binding him to give up, forever, the joys of profanity, alcohol, cards,
dancing, and the theater.
These clouds hung behind and over him, for all his boldness.
Eddie Fislinger, the human being, he despised. He considered
him a grasshopper, and with satisfaction considered stepping on
him. But Eddie Fislinger, the gospeler, fortified with just such a
pebble-leather Bible (bookmarks of fringed silk and celluloid smirking
from the pages) as his Sunday School teachers had wielded when
they assured him that God was always creeping about to catch small
boys in their secret thoughts—this armored Eddie was an official,
and Elmer listened to him uneasily, never quite certain that he might
not yet find himself a dreadful person leading a pure and boresome
life in a clean frock coat.
“—and remember,” Eddie was wailing, “how terribly dangerous it
is to put off the hour of salvation! ‘Watch therefore for you know not
what hour your Lord doth come,’ it says. Suppose this train were
wrecked! Tonight!”
The train ungraciously took that second to lurch on a curve.
“You see? Where would you spend Eternity, Hell-cat? Do you
think that any sportin’ round is fun enough to burn in hell for?”
“Oh, cut it out. I know all that stuff. There’s a lot of arguments
— You wait’ll I get Jim to tell you what Bob Ingersoll said about hell!”
“Yes! Sure! And you remember that on his death-bed Ingersoll
called his son to him and repented and begged his son to hurry and
be saved and burn all his wicked writings!”
 “Well— Thunder— I don’t feel like talking religion tonight. Cut it
out.”
But Eddie did feel like talking religion, very much so. He waved
his Bible enthusiastically and found ever so many uncomfortable
texts. Elmer listened as little as possible, but he was too feeble to
make threats.
It was a golden relief when the train bumped to a stop at
Gritzmacher Springs. The station was a greasy wooden box, the
platform was thick with slush, under the kerosene lights. But Jim was
awaiting him, a refuge from confusing theological questions, and with
a furious “G’night!” to Eddie he staggered off.
“Why didn’t you make him shut his trap?” demanded Jim.
“I did! Whadja take a sneak for? I told him to shut up and he shut
up and I snoozed all the way back and— Ow! My head! Don’t walk
so fast!”
 CHAPTER II

I
for years the state of sin in which dwelt Elmer Gantry and Jim
Lefferts had produced fascinated despair in the Christian hearts of
Terwillinger College. No revival but had flung its sulphur-soaked
arrows at them—usually in their absence. No prayer at the Y. M. C.
A. meetings but had worried over their staggering folly.
Elmer had been known to wince when President the Rev. Dr.
Willoughby Quarles was especially gifted with messages at morning
chapel, but Jim had held him firm in the faith of unfaith.
Now, Eddie Fislinger, like a prairie seraph, sped from room to
room of the elect with the astounding news that Elmer had publicly
professed religion, and that he had endured thirty-nine minutes of
private adjuration on the train. Instantly started a holy plotting against
the miserable sacrificial lamb, and all over Gritzmacher Springs, in
the studies of ministerial professors, in the rooms of students, in the
small prayer-meeting room behind the chapel auditorium, joyous
souls conspired with the Lord against Elmer’s serene and zealous
sinning. Everywhere, through the snowstorm, you could hear
murmurs of “There is more rejoicing over one sinner who repenteth
—”
Even collegians not particularly esteemed for their piety,
suspected of playing cards and secret smoking, were stirred to
ecstasy—or it may have been snickering. The football center, in
unregenerate days a companion of Elmer and Jim but now engaged
to marry a large and sanctified Swedish co-ed from Chanute, rose
voluntarily in Y. M. C. A. and promised God to help him win Elmer’s
favor.
The spirit waxed most fervent in the abode of Eddie Fislinger,
who was now recognized as a future prophet, likely, some day, to
have under his inspiration one of the larger Baptist churches in
Wichita or even Kansas City.
 He organized an all-day and all-night prayer-meeting on Elmer’s
behalf, and it was attended by the more ardent, even at the risk of
receiving cuts and uncivil remarks from instructors. On the bare floor
of Eddie’s room, over Knute Halvorsted’s paint-shop, from three to
sixteen young men knelt at a time, and no 1800 revival saw more
successful wrestling with the harassed Satan. In fact one man,
suspected of Holy Roller sympathies, managed to have the jerks,
and while they felt that this was carrying things farther than the Lord
and the Baptist association would care to see, it added excitement to
praying at three o’clock in the morning, particularly as they were all
of them extraordinarily drunk on coffee and eloquence.
By morning they felt sure that they had persuaded God to attend
to Elmer, and though it is true that Elmer himself had slept quite
soundly all night, unaware of the prayer-meeting or of divine
influences, it was but an example of the patience of the heavenly
powers. And immediately after those powers began to move.
To Elmer’s misery and Jim’s stilled fury, their sacred room was
invaded by hordes of men with uncombed locks on their foreheads,
ecstasy in their eyes, and Bibles under their arms. Elmer was safe
nowhere. No sooner had he disposed of one disciple, by the use of
spirited and blasphemous arguments patiently taught to him by Jim,
than another would pop out from behind a tree and fall on him.
At his boarding-house—Mother Metzger’s, over on Beech Street
—a Y. M. C. A. dervish crowed as he passed the bread to Elmer,
“Jever study a kernel of wheat? Swonnerful! Think a wonnerful
intricate thing like that created itself? Somebody must have created
it. Who? God! Anybody that don’t reconize God in Nature—and
acknowledge him in repentance—is dumm. That’s what he is!”
Instructors who had watched Elmer’s entrance to classrooms with
nervous fury now smirked on him and with tenderness heard the
statement that he wasn’t quite prepared to recite. The president
himself stopped Elmer on the street and called him My Boy, and
shook his hand with an affection which, Elmer anxiously assured
himself, he certainly had done nothing to merit.
He kept assuring Jim that he was in no danger, but Jim was
alarmed, and Elmer himself more alarmed with each hour, each new
greeting of: “We need you with us, old boy—the world needs you!”
Jim did well to dread. Elmer had always been in danger of giving
up his favorite diversions—not exactly giving them up, perhaps, but
of sweating in agony after enjoying them. But for Jim and his
remarks about co-eds who prayed in public and drew their hair back
rebukingly from egg-like foreheads, one of these sirens of morality
might have snared the easy-going pangynistic Elmer by proximity.
A dreadful young woman from Mexico, Missouri, used to coax
Jim to “tell his funny ideas about religion,” and go off in neighs of
pious laughter, while she choked, “Oh, you’re just too cute! You don’t
mean a word you say. You simply want to show off!” She had a
deceptive sidelong look which actually promised nothing whatever
this side of the altar, and she might, but for Jim’s struggles, have led
Elmer into an engagement.
The church and Sunday School at Elmer’s village, Paris, Kansas,
a settlement of nine hundred evangelical Germans and Vermonters,
had nurtured in him a fear of religious machinery which he could
never lose, which restrained him from such reasonable acts as
butchering Eddie Fislinger. That small pasty-white Baptist church
had been the center of all his emotions, aside from hell-raising,
hunger, sleepiness, and love. And even these emotions were
represented in the House of the Lord, in the way of tacks in pew-
cushions, Missionary Suppers with chicken pie and angel’s-food
cake, soporific sermons, and the proximity of flexible little girls in thin
muslin. But the arts and the sentiments and the sentimentalities—
they were for Elmer perpetually associated only with the church.
Except for circus bands, Fourth of July parades, and the singing
of “Columbia, the Gem of the Ocean” and “Jingle Bells” in school, all
the music which the boy Elmer had ever heard was in church.
The church provided his only oratory, except for campaign
speeches by politicians ardent about Jefferson and the price of
binding-twine; it provided all his painting and sculpture, except for
the portraits of Lincoln, Longfellow, and Emerson in the school-
building, and the two china statuettes of pink ladies with gilt flower-
baskets which stood on his mother’s bureau. From the church came
all his profounder philosophy, except the teachers’ admonitions that
little boys who let garter-snakes loose in school were certain to be
licked now and hanged later, and his mother’s stream of opinions on
hanging up his overcoat, wiping his feet, eating fried potatoes with
his fingers, and taking the name of the Lord in vain.
If he had sources of literary inspiration outside the church—in
McGuffey’s Reader he encountered the boy who stood on the
burning deck, and he had a very pretty knowledge of the Nick Carter
Series and the exploits of Cole Younger and the James Boys—yet
here too the church had guided him. In Bible stories, in the words of
the great hymns, in the anecdotes which the various preachers
quoted, he had his only knowledge of literature—
The story of Little Lame Tom who shamed the wicked rich man
that owned the handsome team of grays and the pot hat and led him
to Jesus. The ship’s captain who in the storm took counsel with the
orphaned but righteous child of missionaries in Zomballa. The
Faithful Dog who saved his master during a terrific conflagration
(only sometimes it was a snowstorm, or an attack by Indians) and
roused him to give up horse-racing, rum, and playing the harmonica.
How familiar they were, how thrilling, how explanatory to Elmer of
the purposes of life, how preparatory for his future usefulness and
charm.
The church, the Sunday School, the evangelistic orgy, choir-
practise, raising the mortgage, the delights of funerals, the snickers
in back pews or in the other room at weddings—they were as
natural, as inescapable a mold of manners to Elmer as Catholic
processionals to a street gamin in Naples.
The Baptist Church of Paris, Kansas! A thousand blurred but
indestructible pictures.
Hymns! Elmer’s voice was made for hymns. He rolled them out
like a negro. The organ-thunder of “Nicæa”:
Holy, holy, holy! all the saints adore thee,
Casting down their golden crowns around the glassy sea.
The splendid rumble of the Doxology. “Throw Out the Lifeline,”
with its picture of a wreck pounded in the darkness by surf which the
prairie child imagined as a hundred feet high. “Onward, Christian
Soldiers,” to which you could without rebuke stamp your feet.
Sunday School picnics! Lemonade and four-legged races and the
ride on the hay-rack, singing “Seeing Nelly Home.”
Sunday School text cards! True, they were chiefly a medium of
gambling, but as Elmer usually won the game (he was the first boy in
Paris to own a genuine pair of loaded dice) he had plenty of them in
his gallery, and they gave him a taste for gaudy robes, for marble
columns and the purple-broidered palaces of kings, which was later
to be of value in quickly habituating himself to the more decorative
homes of vice. The three kings bearing caskets of ruby and
sardonyx. King Zedekiah in gold and scarlet, kneeling on a carpet of
sapphire-blue, while his men-at-arms came fleeing and blood-
stained, red blood on glancing steel, with tidings of the bannered
host of Nebuchadnezzar, great king of Babylon. And all his life Elmer
remembered, in moments of ardor, during oratorios in huge
churches, during sunset at sea, a black-bearded David standing
against raw red cliffs—a figure heroic and summoning to ambition, to
power, to domination.
Sunday School Christmas Eve! The exhilaration of staying up,
and publicly, till nine-thirty. The tree, incredibly tall, also incredibly
inflammable, flashing with silver cords, with silver stars, with cotton-
batting snow. The two round stoves red-hot. Lights and lights and
lights. Pails of candy, and for every child in the school a present—
usually a book, very pleasant, with colored pictures of lambs and
volcanoes. The Santa Claus—he couldn’t possibly be Lorenzo
Nickerson, the house-painter, so bearded was he, and red-cheeked,
and so witty in his comment on each child as it marched up for its
present. The enchantment, sheer magic, of the Ladies’ Quartette
singing of shepherds who watched their flocks by nights . . . brown
secret hilltops under one vast star.
And the devastating morning when the preacher himself, the Rev.
Wilson Hinckley Skaggs, caught Elmer matching for Sunday School
contribution pennies on the front steps, and led him up the aisle for
all to giggle at, with a sharp and not very clean ministerial thumb-nail
gouging his ear-lobe.
 And the other passing preachers: Brother Organdy, who got you
to saw his wood free; Brother Blunt, who sneaked behind barns to
catch you on Halloween; Brother Ingle, who was zealous but young
and actually human, and who made whistles from willow branches
for you.
And the morning when Elmer concealed an alarm clock behind
the organ and it went off, magnificently, just as the superintendent
(Dr. Prouty, the dentist) was whimpering, “Now let us all be
particularly quiet as Sister Holbrick leads us in prayer.”
And always the three chairs that stood behind the pulpit, the
intimidating stiff chairs of yellow plush and carved oak borders,
which, he was uneasily sure, were waiting for the Father, the Son,
and the Holy Ghost.
He had, in fact, got everything from the church and Sunday
School, except, perhaps, any longing whatever for decency and
kindness and reason.

II
Even had Elmer not known the church by habit, he would have
been led to it by his mother. Aside from his friendship for Jim
Lefferts, Elmer’s only authentic affection was for his mother, and she
was owned by the church.
She was a small woman, energetic, nagging but kindly, once
given to passionate caresses and now to passionate prayer, and she
had unusual courage. Early left a widow by Logan Gantry, dealer in
feed, flour, lumber, and agricultural implements, a large and
agreeable man given to debts and whisky, she had supported herself
and Elmer by sewing, trimming hats, baking bread, and selling milk.
She had her own millinery and dressmaking shop now, narrow and
dim but proudly set right on Main Street, and she was able to give
Elmer the three hundred dollars a year which, with his summer
earnings in harvest field and lumber-yard, was enough to support
him—in Terwillinger, in 1902.
She had always wanted Elmer to be a preacher. She was jolly
enough, and no fool about pennies in making change, but for a
preacher standing up on a platform in a long-tailed coat she had
gaping awe.
Elmer had since the age of sixteen been a member in good
standing of the Baptist Church—he had been most satisfactorily
immersed in the Kayooska River. Large though Elmer was, the
evangelist had been a powerful man and had not only ducked him
but, in sacred enthusiasm, held him under, so that he came up
sputtering, in a state of grace and muddiness. He had also been
saved several times, and once, when he had pneumonia, he had
been esteemed by the pastor and all visiting ladies as rapidly
growing in grace.
But he had resisted his mother’s desire that he become a
preacher. He would have to give up his entertaining vices, and with
wide-eyed and panting happiness he was discovering more of them
every year. Equally he felt lumbering and shamed whenever he tried
to stand up before his tittering gang in Paris and appear pious.
It was hard even in college days to withstand his mother. Though
she came only to his shoulder, such was her bustling vigor, her swift
shrewdness of tongue, such the gallantry of her long care for him,
that he was afraid of her as he was afraid of Jim Lefferts’ scorn. He
never dared honestly to confess his infidelity, but he grumbled, “Oh,
gee, Ma, I don’t know. Trouble is, fellow don’t make much money
preaching. Gee, there’s no hurry. Don’t have to decide yet.”
And she knew now that he was likely to become a lawyer. Well,
that wasn’t so bad, she felt; some day he might go to Congress and
reform the whole nation into a pleasing likeness of Kansas. But if he
could only have become part of the mysteries that hovered about the
communion table—
She had talked him over with Eddie Fislinger. Eddie came from a
town twelve miles from Paris. Though it might be years before he
was finally ordained as a minister, Eddie had by his home
congregation been given a License to Preach as early as his
Sophomore year in Terwillinger, and for a month, one summer (while
Elmer was out in the harvest fields or the swimming hole or robbing
orchards), Eddie had earnestly supplied the Baptist pulpit in Paris.
 Mrs. Gantry consulted him, and Eddie instructed her with the
dignity of nineteen.
Oh, yes, Brother Elmer was a fine young man—so strong—they
all admired him—a little too much tempted by the vain gauds of This
World, but that was because he was young. Oh, yes, some day
Elmer would settle down and be a fine Christian husband and father
and business man. But as to the ministry—no. Mrs. Gantry must not
too greatly meddle with these mysteries. It was up to God. A fellow
had to have a Call before he felt his vocation for the ministry; a real
overwhelming mysterious knock-down Call, such as Eddie himself
had ecstatically experienced, one evening in a cabbage patch. No,
not think of that. Their task now was to get Elmer into a real state of
grace and that, Eddie assured her, looked to him like a good deal of
a job.
Undoubtedly, Eddie explained, when Elmer had been baptized, at
sixteen, he had felt conviction, he had felt the invitation, and the
burden of his sins had been lifted. But he had not, Eddie doubted,
entirely experienced salvation. He was not really in a state of grace.
He might almost be called unconverted.
Eddie diagnosed the case completely, with all the proper
pathological terms. Whatever difficulties he may have had with
philosophy, Latin, and calculus, there had never been a time since
the age of twelve when Eddie Fislinger had had difficulty in
understanding what the Lord God Almighty wanted, and why, all
through history, he had acted thus or thus.
“I should be the last to condemn athaletics,” said Eddie. “We
must have strong bodies to endure the burden and the sweat of
carrying the Gospel to the world. But at the same time, it seems to
me that football tends to detract from religion. I’m a little afraid that
just at present Elmer is not in a state of grace. But, oh, Sister, don’t
let us worry and travail! Let us trust the Lord. I’ll go to Elmer myself,
and see what I can do.”
That must have been the time—it certainly was during that
vacation between their Sophomore and Junior years—when Eddie
walked out to the farm where Elmer was working, and looked at
Elmer, bulky and hayseedy in a sleeveless undershirt, and spoke
reasonably of the weather, and walked back again. . . .
Whenever Elmer was at home, though he tried affectionately to
live out his mother’s plan of life for him, though without very much
grumbling he went to bed at nine-thirty, whitewashed the henhouse,
and accompanied her to church, yet Mrs. Gantry suspected that
sometimes he drank beer and doubted about Jonah, and uneasily
Elmer heard her sobbing as she knelt by her high-swelling, white-
counterpaned, old-fashioned bed.

III
With alarmed evangelistic zeal, Jim Lefferts struggled to keep
Elmer true to the faith, after his exposure to religion in defending
Eddie at Cato.
He was, on the whole, rather more zealous and fatiguing than
Eddie.
Nights, when Elmer longed to go to sleep, Jim argued; mornings,
when Elmer should have been preparing his history, Jim read aloud
from Ingersoll and Thomas Paine.
“How you going to explain a thing like this—how you going to
explain it?” begged Jim. “It says here in Deuteronomy that God
chased these Yids around in the desert for forty years and their
shoes didn’t even wear out. That’s what it says, right in the Bible.
You believe a thing like that? And do you believe that Samson lost all
his strength just because his gal cut off his hair? Do you, eh? Think
hair had anything to do with his strength?”
Jim raced up and down the stuffy room, kicking at chairs, his
normally bland eyes feverish, his forefinger shaken in wrath, while
Elmer sat humped on the edge of the bed, his forehead in his hands,
rather enjoying having his soul fought for.
To prove that he was still a sound and freethinking stalwart,
Elmer went out with Jim one evening and at considerable effort they
carried off a small outhouse and placed it on the steps of the
Administration Building.
 Elmer almost forgot to worry after the affair of Eddie and Dr.
Lefferts.
Jim’s father was a medical practitioner in an adjoining village. He
was a plump, bearded, bookish, merry man, very proud of his
atheism. It was he who had trained Jim in the faith and in his choice
of liquor; he had sent Jim to this denominational college partly
because it was cheap and partly because it tickled his humor to
watch his son stir up the fretful complacency of the saints. He
dropped in and found Elmer and Jim agitatedly awaiting the arrival of
Eddie.
“Eddie said,” wailed Elmer, “he said he was coming up to see me,
and he’ll haul out some more of these proofs that I’m going straight
to hell. Gosh, Doctor, I don’t know what’s got into me. You better
examine me. I must have anemics or something. Why, one time, if
Eddie Fislinger had smiled at me, damn him, think of him daring to
smile at me!—if he’d said he was coming to my room, I’d of told him,
‘Like hell you will!’ and I’d of kicked him in the shins.”
Dr. Lefferts purred in his beard. His eyes were bright.
“I’ll give your friend Fislinger a run for his money. And for the
inconsequential sake of the non-existent Heaven, Jim, try not to look
surprised when you find your respectable father being pious.”
When Eddie arrived, he was introduced to a silkily cordial Dr.
Lefferts, who shook his hand with that lengthiness and painfulness
common to politicians, salesmen, and the godly. The doctor rejoiced:
“Brother Fislinger, my boy here and Elmer tell me that you’ve
been trying to help them see the true Bible religion.”
“I’ve been seeking to.”
“It warms my soul to hear you say that, Brother Fislinger! You
can’t know what a grief it is to an old man tottering to the grave, to
one whose only solace now is prayer and Bible-reading”—Dr.
Lefferts had sat up till four a. m., three nights ago, playing poker and
discussing biology with his cronies, the probate judge and the
English stock-breeder—“what a grief it is to him that his only son,
James Blaine Lefferts, is not a believer. But perhaps you can do